Can cosmetic surgery tame its Wild West?

by Emma Charlton

From US "Botox parties" to Asia's craze for eyelid jobs or Brazilian bum lifts, millions now reshape their bodies through cosmetic surgery each year.

But the booming industry is battling a Wild West of rogue practices, cruelly highlighted by the French breast implant scandal.

Until the 1990s, "there was a veil of secrecy around cosmetic procedures," says Sander Gilman, psychiatry professor at Emory University in the United States, and author of several books on cosmetic surgery.

In the 21st century world, you can fly to Turkey or India for a cut-price breast job, sign up for a surgical full-body makeover on reality TV, or curl up in front of an episode of the hit plastic surgery-themed series "Nip/Tuck".

What happened in between? How did practices until recently seen as shameful, unethical, even taboo, become close to commonplace, in a rapid and remarkable shift in values?

The short answer, by and large, is Botox -- or Botulinum toxin -- a poisonous substance which when injected in small doses masks wrinkles by temporarily paralysing the facial muscles, and which became widely available in the 1990s.

"Suddenly cosmeticians were doing Botox injections, people were having Botox parties injecting each other," said Gilman.

"Botox caused a ripple effect where the next stage -- having surgical procedures -- became more acceptable," he said. "A facelift became something you talked about. Cosmetic surgery became ordinary."

Worldwide in 2010, plastic surgeons carried out an estimated 18.5 million operations, according to the International Society of Aesthetic Plastic Surgery (ISAPS), a non-profit group representing surgeons in 93 countries.

The United States tops the list, with 3.3 million operations, followed by Brazil, then China, Japan and India, according to ISAPS projections based on a survey of 698 surgeons worldwide.

Half are for full surgery, with liposuction and breast augmentation the most popular operations, while the rest are for non-surgical procedures.

The fastest growth area for the multi-billion-dollar market, these non-surgical treatments include injections of Botox, of so-called "skin fillers" such as hyaluronic acid or body fat, and a dozen procedures from laser hair removal to chemical peeling.

-- 'We see catastrophes on a monthly basis' --

The true figures are probably far higher since ISAPS only counts work carried out by registered plastic surgeons.

"The problem worldwide is that a very, very large number of people who are not educated in surgery are starting to offer aesthetic surgery," said the president of ISAPS, the Swiss-based plastic surgeon Jan Poell.

Today general practitioners can legally offer breast augmentations or liposuctions, without specific training. The same applies to beauticians, who can legally perform non-surgical work like skin filler injections.

"We see catastrophes on a monthly basis: asymmetries, expulsions of implants, facial palsy, eyelids that can't close anymore," resulting from botched operations performed in places like Taiwan or Eastern Europe, Poell said.

Skin fillers -- which like breast implants are not considered to be medicines -- are a grey area, with Europe lagging behind the United States when it comes to regulating what products can be injected and by whom.

Cosmetic surgeons meeting in Paris on January 27 for the International Master Class on Ageing (IMCAS) congress are set to release a study on complications linked to injections, as part of a push for tighter regulation.

According to the French sanitary authority AFSSAPS, between 0.1 and one percent of patients suffer serious side effects after a skin filler injection.

Because most skin filler products have temporary effects, the likelihood of a full-blown sanitary scandal is limited.

"Most of the fillers are like Botox: by the time you get to court they've worn off," said consultant plastic surgeon Douglas McGeorge, who sits on the council of the British Association of Aesthetic Plastic Surgeons, (BAAPS).

But when it comes to surgery there are horror stories -- at least half a dozen of them reported in recent years -- of people dying following backstreet cosmetic operations, often as a result of complications from anaesthesia.

There are no global figures on cases of botched cosmetic surgery, but the unfolding breast implant scandal has spotlighted how badly things can go wrong when dishonesty is thrown into the bargain.

Some 300,000 women in 65 countries are estimated to have received implants produced by the now defunct French company, Poly Implant Prothese (PIP), which allegedly used an illegal industrial-grade gel that investigators say has led to abnormally high rupture rates.

France has already advised the removal of the implants, while 13 countries in Europe and in Latin America have urged women to seek regular checkups.

Poell believes we are unlikely to witness another implant scandal: "Everybody will be very, very careful. And if people become more alert, the scandal could even have a positive side effect."

To combat rogue practice, ISAPS runs public education programmes and offers insurance for consumers who seek surgery aboard, guaranteeing treatment for possible complications so long as they use an ISAPS-approved surgeon.

As a rule of thumb, Poell said, low cost surgery -- wherever it is offered -- should set off alarm bells.

"Good plastic surgery has the same price everywhere," he said. "If you can get a breast augmentation in another country for less than what I pay for an implant, then something is wrong.

Patients can decrease the frequency of Botox Cosmetic injections after approximately two years and still receive most of the same wrinkle-smoothing cosmetic benefits, according to new research at Oregon Health & Science University.

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